Domestic Violence As a Public Health Issue s1
Domestic Violence & Health
in North Carolina:
Planning and Implementing
Response Programs in Healthcare Settings
Prepared by
Corrine Munoz-Plaza, MPH
Jan Capps, MPH
The Beacon Program
Prepared for
The Governor’s Crime Commission
The North Carolina Department of
Crime Control and Public Safety
January 2001
Grant #: 180-1-98-4VA-W-020
Grant #: 180-2-99-4VA-W-020
Domestic Violence & Health in
North Carolina: Planning and Implementing Response Programs in Healthcare Settings
Prepared by
Corrine Munoz-Plaza, MPH
Jan Capps, MPH
The Beacon Program
Prepared for
The Governor’s Crime Commission
The North Carolina Department of Crime Control and Public Safety
University of North Carolina Hospitals
The Beacon Program
Effective Practices Project
Campus Box 7600, 101 Manning Drive
Chapel Hill, NC 27514
Phone (919) 966-9314 Fax (919) 966-9315
http://www.med.unc.edu/wrkunits/3ctrpgm/beacon/
January 2001
Ordering Information
This manual may be ordered from The Beacon Program by writing to Campus Box #7600, University of North Carolina Hospitals, Chapel Hill, NC 27514 or by calling (919) 966-9314. The charge is $3.00, which covers postage and handling. Please make payment by check or money order to “The Beacon Program.”
Acknowledgements
This project was generously supported by Federal Formula Grant # 180-1-98-4VA-W-020 and l80-2-99-4VA-W-020, awarded by the Bureau of Justice Assistance, U.S. Department of Justice through the North Carolina Department of Crime Control and Public Safety/Governor’s Crime Commission. Points of view or opinions contained within this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.
We want to also thank the North Carolina healthcare organizations that participated in the Effective Practices for Healthcare Response to Domestic Violence Project. We greatly appreciate the cooperation, hard work and dedication displayed by all five sites to the issue of domestic violence and the efforts made to plan and develop their own healthcare-based domestic violence response programs. Those sites include: Lenoir Memorial Hospital, Lenoir County; Cleveland Regional Medical Center, Cleveland County; New Hanover Regional Medical Center, New Hanover County; Rural Health Group, Northampton County; and Robeson Health Care, Robeson County.
Finally, we greatly appreciate the guidance, feedback, and assistance provided by the Effective Practices Project’s Statewide Multidisciplinary Team members, which include: Jill Silverman, MD, Diana Solkoff, MPH, Diana Wells, MPH, MSW, RN, Peggy Goodman, MD, Amy Holloway, MSW, Thomas Williams, Janice Kraft, Paige Hall Smith, Ph.D, and Anna Waller, Sc.D. Each member of the team offered invaluable experience and expertise in the areas of domestic violence, data collection and evaluation, and the planning, development and implementation of healthcare-based domestic violence response programs.
Table of Contents
Introduction 1
About This Manual 3
Definition of Terms 5
Chapter I: Domestic Violence & Health 6
Definition of Domestic Violence 6
Learning to Recognize Domestic Violence 7
Impact of Domestic Violence on Health Status 8
Health-related Indicators of Domestic Violence 8
Healthcare Domestic Violence Statistics 9
Role of the Healthcare Provider in Addressing Domestic Violence 10
Chapter II: Planning an Institutional Response 12
Gain Administrative Support 12
Form a Multidisciplinary Planning Team 13
Conduct Needs Assessment 14
Patient Assessment 15
Clinician Assessment 16
Healthcare Organization Assessment 17
Community Resources Assessment 18
Summary of Findings from North Carolina Healthcare Organizations 18
Intervention model 24
Example Program Models 27
Chapter III: Developing Program Components 28
Program Components 28
Domestic Violence Multidisciplinary Planning Team 29
Domestic Violence Policies & Protocols 30
Clinical Intervention Services 34
Identification 37
Assessment 42
Intervention 45
Documentation of abuse 49
Discharge planning 52
Follow-up with patients 53
Staff Training and Education 54
Patient Education 56
Community Linkages 56
Determining Program Success 58
Chapter IV: Program Implementation 59
Developing a Budget and Acquiring Resources 59
Institutionalizing Routine Screening 60
Administering Provider Training 61
Marketing the Program 61
Determining Program Success 62
References 66
Appendices 68
Appendix A - Effective Practices for Healthcare Response 68
Appendix B - Domestic Violence Resources 73
Appendix C.1 - Patient Survey 84
Appendix C.2 - Clinician Survey 86
Appendix C.3 - Healthcare Organization Assessment 93
Appendix C.4 - Community Resources Assessment 99
Appendix D - Patient Data: Background & Identifying Information 101
Appendix E - Legal Issues for Healthcare Providers 102
Appendix F - Consent to Photograph 108
Appendix G - Danger Assessment 109
Appendix H - Safety Plan I 111
Appendix I - Safety Plan II 113
Appendix J - Body Map 120
Addendum (separate documents)
Identification, Documentation and Reporting of Child Maltreatment
Identification, Documentation and Reporting of Child Exposure to Domestic Violence
Elder Abuse and Neglect
Introduction
Approximately 4 million women experience domestic violence at the hands of an intimate partner each year (Sassetti, 1993). Because batterers tend to isolate their female partners from family, friends, and services, a visit to the doctor’s office, health clinic or emergency department may be one of the few times a woman comes into contact with professionals in a confidential setting. Early intervention is critical, because violence is almost always repeated, often escalates in severity over time and can ultimately lead to a number of acute and chronic health problems for victims.
In 1992, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) recognized the important role healthcare organizations play in assisting domestic violence victims. In fact, JCAHO now requires accredited healthcare organizations to establish domestic violence policies and protocols in emergency and ambulatory care departments. The American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association also recognize the responsibility healthcare professionals have in addressing domestic violence and have issued their own guidelines for identification and treatment. Such policies and guidelines underscore the importance of identification, treatment and referral of domestic violence victims in healthcare settings.[1]
Such guidelines can provide a solid foundation to build upon when planning, developing and implementing domestic violence response programs in healthcare settings. By establishing clear policies and protocols for domestic violence screening, assessment, intervention, referral and follow-up, healthcare organizations can accomplish three main goals. These goals are:
increasing the rates at which clinicians and staff identify battered women
improving the care provided to patients experiencing domestic violence
coordinating services with local domestic violence agencies and streamlining referral services to appropriate community resources
About This Manual
The Beacon Program at the University of North Carolina Hospitals is a hospital-based domestic violence intervention program. Established in 1996, the goal of the Beacon Program is to provide health assessment, counseling, case-management, and community referral for battered women seen in the inpatient and outpatient clinics of University of North Carolina Hospitals. The objectives of the program are to provide services via patient advocacy, counseling, educational services, medical care, and case-management to victims of domestic violence, as well as training to staff and faculty in the assessment, diagnosis, treatment, care and referral of abuse victims. In addition, Beacon Program staff network with community agencies that serve victims of violence to develop coordinated services and referrals.
In 1998, the Beacon Program was funded by the North Carolina Governor’s Crime Commission to develop the Effective Practices for Healthcare Response to Domestic Violence project (EPHRDV). The goal of the project was to provide technical assistance to five healthcare organizations throughout North Carolina in the planning and development of each site’s own domestic violence response program. The organizations in North Carolina that agreed to participate in EPHRDV include: Lenoir Memorial Hospital, Lenoir County; Cleveland Regional Medical Center, Cleveland County; New Hanover Regional Medical Center, New Hanover County; Rural Health Group, Northampton County; and Robeson Healthcare, Robeson County. Technical assistance was provided to each site on forming a multidisciplinary planning team, conducting a needs assessment, holding a planning workshop for site administrators, clinicians and local community agencies, implementation of program components, and evaluation of the program after one year. For a more detailed description of the technical assistance provided to each site, refer to Appendix A.
Informed by working with each of these five healthcare organizations, this manual is provided as a resource for healthcare organizations and community agencies interested in developing a comprehensive response to domestic violence in a healthcare setting. Whether the organization is a large hospital, regional medical center, or a rural community health center, this manual provides information pertinent to the planning, development and evaluation of programs focusing on intimate partner violence. This manual can both provide technical assistance to administrators, management personnel and other stakeholders in a number of organizational settings (e.g., urban/rural, inpatient/outpatient) and serve as a resource for a wide array of clinicians and healthcare providers.
Chapter 1 of this manual defines domestic violence and discusses the relationship between domestic violence and health. Chapter 2 provides suggestions for planning a healthcare-based domestic violence response program, including gaining administrative support for the program, forming a multidisciplinary domestic violence planning team, conducting a needs assessment, and selecting a program intervention model. Chapter 3 discusses the development of program components for a healthcare-based domestic violence response program. Program components that are discussed in this chapter include the role of a domestic violence team, policies and protocols, clinical intervention services, training, patient education, networking with community-based agencies and data collection. Chapter 4 presents strategies for implementing a healthcare-based domestic violence response program.
In addition, many model materials are offered throughout the manual and in the Appendices. CEO’s, administrators, department managers and community members interested in developing a comprehensive domestic violence program within a healthcare setting may want to use this manual from beginning to end to guide them in this process. However, other healthcare professionals may find certain sections more appropriate to their needs. Whether you or your organization choose to use the manual in its entirety or prefer to reference specific sections, it is the authors’ hope that the information provided will assist you in improving health services to victims of domestic violence.
Healthcare provider includes:
Nurses Physicians
Social Workers Medical Students
Mental Health Practitioners Emergency Medical Services Technicians Physical Therapists
Occupational Therapists Other Clinical or Non-Clinical Staff
Allied Health Professionals Family Nurse Practitioners
Physician Assistants
Community Agencies include:
Community DV Shelters/Programs Police Departments
Sheriff’s Departments Department of Social Services
Community Mental Health Programs Batterers Treatment Programs
Victim Assistance Programs Teen Violence Projects
Other Domestic Violence Agencies
Intimate partners can be:
Married or Common Law Partners Legally Separated Partners
Legally Divorced Partners Current or Former Boyfriends
Current or Former Girlfriends Current or Former Same-Sex Partners
Current or Former Dating Partners
5
Chapter I
Domestic Violence
& Health
Domestic Violence and Health
Definition of Domestic Violence
Domestic violence is defined as chronic abuse by one current or former intimate partner against the other for the purpose of control, domination, and/or coercion. Domestic violence can include acts of physical, emotional and sexual abuse. Domestic violence episodes are not simply random acts of violence or incidents of mere loss of temper; rather, such episodes are part of a complex, continuing pattern of behavior of which violence is only one component. The Centers for Disease Control and Prevention use the term intimate partner violence to refer to domestic violence. Under this definition, intimate partners can include current or former spouses, as well as boyfriends or girlfriends of both heterosexual and same-sex relationships.
Learning to Recognize Domestic Violence…
Impact of Domestic Violence on Health Status
Physical health consequences of domestic violence can include injury and death, gastrointestinal problems, chronic pain, sleeping and eating disorders, HIV/STDs, miscarriage, and unwanted pregnancies. Psychological consequences can include depression, suicidal thoughts and attempts, lowered self-esteem, post-traumatic stress disorder, and alcohol and other drug abuse.
Possible health-related indicators of abuse include…
Mental health issues Eating disorders
Self mutilation Fear
Headaches Crying jags
Delay in obtaining prenatal care Multiple injuries 
Role of the Healthcare Provider in Addressing Domestic Violence
Providers and advocates can potentially reach and assist large numbers of women experiencing intimate partner violence through the development of effective response programs within various healthcare settings.
Unfortunately, women may have already faced resistance and barriers in obtaining help from family, friends, and other service providers. Recognizing these barriers can help providers understand why women may be hesitant to talk about abuse.
Through patient advocacy, healthcare providers can empower patients by:
Helping them build self-respect
Minimizing their feelings of humiliation and self blame
Underscoring that violence is not acceptable
Improving patient care
Preventing the prescription of harmful therapies
Although healthcare providers have the potential to play an important role in supporting women with an abuse history, overall response to victims of domestic violence has been poor. Few healthcare providers identify the role domestic violence can play in their patients’ lives.
Examination of training programs for healthcare providers also reveals that few have incorporated information on domestic violence. Sugg and Inui (1992) observed that 61% of practicing physicians did not receive violence education, either during medical school, residency, or continuing education. One study asked a national sample of 1,000 women about where they had received help for domestic violence. Although medical personnel were utilized rather frequently, they were viewed by these women as less effective than any other group, including social workers, clergy, police, lawyers, and domestic violence advocates (Bowker & Maurer, 1987).
JCAHO Standards
In order to address the issue of domestic violence within healthcare organizations, the Joint Commission for the Accreditation of Healthcare Organizations issued standards (1992) related to the identification, treatment and referral of victims of domestic violence. For more information on JCAHO standards, visit their web site at www.jcaho.org or call (630) 792-5000.
11
Chapter II